Chapter 23: The Elbow

Jennifer Doherty-Restrepo, MS, LAT, ATC Academic Program Director, Entry-Level ATEP Florida International University Acute Care and Injury Prevention

Anatomy of the Elbow

Review

Functional Anatomy

Elbow ROM = flexion, extension, pronation and supination

145 degrees of flexion 90 degrees of supination and pronation

Stable joint: protection from overuse and traumatic injuries

Bony limitations, ligamentous support, and muscular stability at the elbow help to Normal in females is 10-15 degrees, males 5 degrees

Carrying angle due to distal projection of humerus

Critical link in kinetic chain of upper extremity

Assessment of the Elbow: History

Past history Mechanism of injury When does it hurt? Where does it hurt? Motions that increase pain? Motions that decrease pain?

Type of, quality of, duration of, pain? Sounds or feelings? How long were you disabled? Swelling? Previous treatments?

Observations

Deformities and swelling? Carrying angle

Cubitus valgus vs. Cubitus varus Cubitus recurvatum

Flexion and extension

Elbow at 45 degrees

Isosceles triangle formed by the olecranon and epicondyles

Palpation: Bony and Soft Tissue

Humerus Medial and lateral epicondyles Olecranon process Radial head Radius Ulna Medial and lateral collateral ligaments Annular ligament

Biceps brachii Brachialis Brachioradialis Pronator teres Triceps Supinator Wrist flexors Wrist extensors

Special Tests: Circulatory and Neurological Function

Pulse

Assessed at brachial artery and radial artery Determine presence of nerve root compression or irritation in cervical or shoulder region Ulnar nerve test Tap on ulnar nerve in ulnar groove Positive test = numbness/tingling along the forearm and hand

Skin sensation Tinels sign

Special Tests: Capsular Injury

Tested after hyperextension of elbow Athlete position

Elbow is flexed to 45 degrees Wrist is fully flexed and extended If joint pain is severe, sprain or fracture should be suspected Joint pain may indicate chronic injury as well

Positive test = pain in elbow joint

Special Tests: Ligament Injury

Valgus/Varus Stress Test

Assess injury to the medial and lateral collateral ligaments, respectively Positive test = joint laxity or complaint of pain

Special Tests: Muscle Injury

Medial Epicondylitis Test

Athlete position

Elbow flexed to 45 degrees Resist wrist flexion

Positive test = pain at medial epicondyle

Lateral Epicondylitis Test

Athlete position

Elbow flexed to 45 degrees Resist wrist extension

Positive test = pain at lateral epicondyle

Special Tests: Muscle Injury

Pinch Grip Test

Pinch thumb and index finger together Positive test = inability to touch fingers together

Indicates entrapment of anterior interosseous nerve between the heads of pronator muscle

Pronator Teres Syndrome Test

Resist forearm pronation Positive test = increased pain over pronator teres

Special Tests: Functional Evaluation

Evaluate AROM, PROM and RROM

Flexion Extension Pronation Supination

Positive test = pain and weakness

Elbow Injuries

Subject to injury due to

Broad range of motion Weak lateral bone structure Exposure of soft tissue Locking motion of some activities Use of implements Throwing motion

Many sports place excessive stress on joint

Elbow Injuries: Contusion

MOI = direct blow or repetitive blows

Vulnerable area due to lack of padding

Signs and Symptoms

Rapid swelling due to irritation of bursa or synovial membrane

PRICE immediately, for at least 24 hours If severe, refer for X-ray to rule out fracture

Management

Elbow Injuries: Olecranon Bursitis

MOI = direct blow

Superficial location makes it extremely susceptible to injury Pain, swelling, and point tenderness Swelling will appear almost spontaneously without the pain and heat

Signs and Symptoms

Management

Acute: compression for at least 1 hour Chronic: requires superficial therapy primarily involving compression If swelling fails to resolve, aspiration may be necessary May be padded to return to competition

Elbow Injuries: Muscle Strains

MOI = overstretching or too forceful a contraction

Falling on outstretched arm Repeated microtears may cause chronic injury

Rupture of distal biceps is most common in UE

Signs and Symptoms

Pain with AROM and RROM Point tenderness in muscle, tendon, or lower part of muscle belly

Elbow Injuries: Muscle Strains

Management

PRICE Sling in severe cases Follow-up treatment

Cryotherapy, ultrasound, ROM and PRE exercises

If severe loss of function, refer for X-ray to rule out avulsion or epiphyseal fracture

Elbow Injuries: Ulnar Collateral Ligament Injuries

MOI = valgus force from repetitive trauma Secondary injuries may include

Ulnar nerve inflammation Wrist flexor tendinitis Overuse flexor/pronator strain Ligamentous sprains Elbow flexion contractures Joint instability

Signs and Symptoms

Pain along medial aspect of elbow Point tenderness over UCL Associated paresthesia

Positive Tinels sign Possible end-point laxity Hypertrophy of humeral condyle and/or posteromedial aspect of olecranon; and osteophytes Calcification within the UCL Loose bodies in posterior compartment

Positive Valgus Stress Test

X-ray may show evidence of

Management

Conservative treatment

PRICE and NSAIDs

ROM and PRE exercises as pain decreases Analysis of the throwing motion (if applicable) Surgical intervention may be necessary

Tommy John Procedure Throwing athlete may be able to return to activity approximately 22-26 weeks post surgery

Elbow Injuries: Lateral Epicondylitis (Tennis Elbow)

MOI = repetitive microtrauma to insertion of wrist extensor muscles

Tendinosis may result

Degeneration of tendon without inflammation

Signs and Symptoms

Aching pain at lateral epicondyle after activity Decreased elbow ROM Pain with AOM and RROM wrist extension Pain and weakness in wrist and hand develop

Management

PRICE NSAIDs and analgesics Mobilization and stretching in pain free ranges

ROM and PRE exercises as pain decreases

Deep friction massage Hand grasping while in supination

Avoid pronation motions

Use of neoprene sleeve Mechanics and skills training in order to avoid recurrence of injury

Elbow Injuries: Medial Epicondylitis

MOI = repeated forceful wrist flexion and extreme valgus torque on the elbow

May involve pronator teres, flexor carpi radialis, flexor carpi ulnaris, and palmaris longus tendons Can be associated with ulnar nerve neuropathy

Signs and Symptoms

Pain with AOM and RROM wrist extension

Pain with wrist flexion as well in severe injuries

Point tenderness and mild swelling at medial epicondyle

Management

PRICE NSAID's and analgesics Sling in severe cases

Severe cases may require splinting and complete rest for 7-10 days

Cryotherapy, Ultrasound Curvilinear brace

Below elbow to reduce stress at the elbow joint

Elbow Injuries: Osteochondritis Dissecans

MOI = Repetitive microtrauma

Injurious movements include elbow rotation and extension

Excessive valgus stresses causes compression of the radial head, which adds shearing forces at the radiocapitular joint Impairment of blood supply may result, which causes degeneration of articular cartilage creating loose bodies

Panners disease

Occurs in children (age <10) Osteochondrosis of capitellum due to localized avascular necrosis

Signs and Symptoms

Sudden pain at radiohumeral joint Swelling, creptitus Decreased ROM (full extension)

ROM usually returns in a few days Grating with pronation and supination

Locking of the joint X-ray

May show flattening and crater of capitulum May show loose bodies in joint

Management

Activity restriction for 6-12 weeks NSAIDs Splint and cast applied in severe cases of deterioration If repeated locking of the elbow joint occurs, loose bodies are removed surgically

Elbow Injuries: Little League Elbow

MOI = repetitive microtraumas that occur from throwing motion (Not due to the type of pitch) Linked to:

Accelerated apophyseal growth and delayed medial epicondyle epiphysis growth Traction apophysitis with possible fragmentation of medial epicondylar apophysis Avulsion fracture at medial epicondyle or radial head Osteochondrosis of humeral capitellum Non-union stress fracture of olecranon epiphysis

Signs and Symptoms

Onset is slow Slight flexion contracture Tight anterior joint capsule Weakness in triceps Locking or Catching sensation Decreased ROM

Especially forearm pronation and supination

Management

PRICE NSAIDs and analgesics Stop throwing until

Pain resolved Full ROM is regained

Gentle ROM exercises Gently triceps strengthening exercises Analysis of throwing motion

Elbow Injuries: Cubital Tunnel Syndrome

MOI = narrowing of cubital canal or irregularity of cubital tunnel

Pronounced cubital valgus may cause deep friction contributing to injury Ulnar nerve injury may result

Ulnar nerve subluxation or dislocation Traction of ulnar nerve from valgus force Ulnar nerve compression from ligaments

Signs and Symptoms

Pain on medial aspect of elbow

Pain may be referred proximally or distally

Point tenderness in cubital tunnel Pain with hyperflexion Intermittent paresthesia in 4th and 5th fingers

Management

Rest, immobilization for 2 weeks NSAIDs Splinting, surgical decompression or transposition of subluxating nerve may be necessary Avoid hyperflexion and valgus stresses

Elbow Injuries: Dislocation

MOI = fall on outstretched hand with elbow extended or severe twist while elbow flexed

High incidence in sports Dislocation may be posterior, anterior, or lateral Swelling, severe pain, disability Median and radial nerves may be compromised Blood vessels may be compromised Often a radial head fracture is involved

Signs and Symptoms

Management

Pack with ice and apply sling immediately Refer for reduction immediately Following reduction

Immobilize in elbow flexion for 3 weeks PRE exercises for grip and shoulder strenthening Heat and PROM exercises to regain full ROM ROM and PRE exercises should be initiated by athlete

Following immobilization

Exercises that are too strenuous should be avoided before complete healing due to high probability of developing myositis ossificans Forced stretching should be avoided

Elbow Injuries: Fractures

MOI = fall on flexed elbow or direct blow

May occur in one or more of bones in elbow joint Fall on outstretched hand may fracture the humerus above condyles or between condyles

Condylar fracture may result in gunstock deformity

Direct blow may fracture olecranon or radial head May not result in visual deformity Hemorrhaging, swelling, muscle spasm

Signs and Symptoms

Management

Monitor neurovascular status Non-surgical treatment

Appropriate for stable fractures Immobilize with cast or removable splint for 6-8 weeks Used to stabilize unstable fractures in adults ROM exercises initiated early to prevent frozen elbow

Surgical treatment

Elbow Injuries: Volkmanns Contracture

MOI = impaired circulation or ischemia

Associate with humeral supracondylar fractures, which compromises the brachial artery and inhibits circulation to forearm May be loss of motor and sensory function

Classic case involves median nerve

Edema further impairs circulation via condition called compartment syndrome

Muscle necrosis may occur with irreversible muscle damage after 4-6 hours, which may lead to secondary fibrosis and calcification

Signs and Symptoms

Pain in forearm which increases with PROM finger extension Cessation of brachial and radial pulses Coldness in arm Decreased ROM Monitor neurovascular integrity

Management

Rehabilitation of the Elbow

General Body Conditioning

Must maintain pre-injury CV and LE strength fitness levels Restoring ROM is critical in elbow rehab Variety of approaches can be used as long as they do not force the joint

Flexibility

Joint Mobilizations

Loss of proper arthrokinematics following immobilization is expected Joint mobilization and traction

Very useful to increase mobility Useful to decrease pain Restores accessory motions

Strengthening

Achieved through low-resistance, high-repetition exercises

Must be pain free

Shoulder and hand grip exercises Isometrics can be used while immobilized PNF and isokinetics are useful in early and intermediate stages of rehabilitation PRE exercises with tubing, weights, or manual resistance Closed kinetic chain activities

Assist in both static and dynamic stability to the elbow

Proprioceptive training should also incorporated

Functional Progressions

Will enhance healing and performance

PNF, swimming, pulley machines, and rubber tubing Simulate sports activities
Warm-up Gradual build up to activity, becoming increasingly more difficult

Should include steps

Return to Activity

ROM must be WNL Strength should be restored without pain